Chatelain C, Conort P, Chartier-Kastler E, Boyer C, Bianchini J M, Richard F
Clinique urologique, Groupe Hospitalier Pitié-Salpêtrière, Paris.
Bull Acad Natl Med. 1999;183(3):615-34; discussion 634-7.
Surgical treatment, mainly transurethral resection of the prostate, still remains the reference treatment for benign prostatic hyperplasia (BPH). Two studies conducted in the Urology Department of the Pitié-Salpêtrière Hospital have tried to define certain characteristics of this surgery. The first study tried to evaluate the long-term outcome of patients operated for benign prostatic hyperplasia. Analysis of 881 replies to a questionnaire sent to 3,147 patients operated for BPH (between 1976 and 1989) assessed functional status (by Madsen's symptom score), quality of life (by Fowler's method), and sex life (by two specific questions), with a follow-up ranging from 5 to 14 years. At this follow-up, 90% of patients declared to be satisfied with their voiding status, 95% considered their quality of life to be excellent and about 50% had maintained a sex life. The second study was designed to evaluate the morbidity of this treatment in elderly patients. A group of 33 operated patients over the age of 80 was compared to a control group composed of 66 patients between the ages of 60 and 70 years, treated in a similar way, in the same centre and in the same year. Morbidity was higher in the first group, but age itself did not appear to constitute a poor prognostic factor for surgery; it only intervenes by allowing certain complications of benign prostatic hyperplasia (acute retention) to create emergency situations complicating the perioperative period. Following demonstration of the short-term and long-term efficacy of this conventional surgery, many new technologies were subsequently developed in order to reduce perioperative discomfort, anaesthetic requirements, duration of catheterization and hospital stay. Some of them constitute a new approach to endoscopic surgery, such as prostatic tissue vaporization techniques (electrovaporization, laser contact vaporization), which have a comparable efficacy to that of TURP, while reducing bleeding, catheterization time and hospital stay. However, the duration of postoperative irritative symptoms is much longer. Other techniques use a thermal effect to obtain coagulation necrosis of prostatic tissue, using various energy sources: microwaves (thermotherapy), laser (interstitial laser), radiofrequency waves (TUNA). These techniques are perfectly adapted to outpatient surgery with local or regional anaesthesia. They do not interfere with continence, sexual function, but may be followed by high dysuria or retention rates, with a variable cathererization time, sometimes several weeks. Finally, urethroprostatic stents are easy to insert, provide a solution in critical situations and have replaced old indwelling catheters. The current choice of treatment therefore comprises several approaches: more effective, but still purely symptomatic medical treatment, safe conventional surgery providing excellent long-term results, but generating a certain perioperative discomfort and a certain morbidity, or, on the contrary "minimally invasive" techniques, greatly simplifying the therapeutic procedure, but whose morbidity has not yet been determined and whose results are still uncertain.
手术治疗，主要是经尿道前列腺切除术，仍然是良性前列腺增生（BPH）的参考治疗方法。皮提耶 - 萨尔佩特里埃医院泌尿外科进行的两项研究试图确定这种手术的某些特征。第一项研究试图评估接受良性前列腺增生手术患者的长期预后。对1976年至1989年间接受BPH手术的3147名患者发出的问卷中的881份回复进行分析，评估功能状态（采用马德森症状评分）、生活质量（采用福勒方法）和性生活（通过两个特定问题），随访时间为5至14年。在此次随访中，90%的患者表示对排尿状态满意，95%的患者认为其生活质量极佳，约50%的患者维持了性生活。第二项研究旨在评估这种治疗方法在老年患者中的发病率。将一组33名年龄超过80岁的手术患者与一个由66名年龄在60至70岁之间、在同一中心、同一年以类似方式治疗的对照组进行比较。第一组的发病率较高，但年龄本身似乎并不是手术的不良预后因素；它只是通过使良性前列腺增生的某些并发症（急性尿潴留）引发紧急情况，从而使围手术期复杂化。在证明了这种传统手术的短期和长期疗效之后，随后开发了许多新技术，以减少围手术期的不适、麻醉需求、导尿时间和住院时间。其中一些构成了内镜手术的新方法，如前列腺组织汽化技术（电汽化、激光接触汽化），其疗效与经尿道前列腺切除术相当，同时减少了出血、导尿时间和住院时间。然而，术后刺激性症状的持续时间要长得多。其他技术利用热效应通过各种能量源使前列腺组织发生凝固性坏死：微波（热疗法）、激光（间质激光）、射频波（经尿道针刺消融术）。这些技术非常适合在局部或区域麻醉下的门诊手术。它们不影响控尿、性功能，但可能随后出现高尿痛或尿潴留率，导尿时间不一，有时长达数周。最后，尿道前列腺支架易于插入，在危急情况下提供一种解决方案，并且已经取代了旧的留置导尿管。因此，目前的治疗选择包括几种方法：更有效但仍然纯粹是对症治疗的药物治疗、安全的传统手术可提供出色的长期效果，但会产生一定的围手术期不适和一定的发病率，或者相反，“微创”技术极大地简化了治疗程序，但其发病率尚未确定且结果仍然不确定。
